Behavioral-Activation-for-Depression

Have you ever noticed that certain things that you do influence your
mood or anxiety? For example: When you listen to sad music do you
ever notice feeling sad for longer periods of time? Do you ever feel
less motivated to apply for a job or school when you are actively
worrying?
Behavioral activation is one of the most important CBT skills used in
treating depression. It has to do with the way that behaviors and
feelings influence each other.
In this chapter we’ll learn how your behavior can directly affect your
mood, for better or worse, and how to use skills to put ourselves in
situations that will make it most likely to improve our mood.
5.1
Behavioral Activation (BA) is a specific CBT skill. It can
be a treatment all by itself, or can be used alongside
other CBT skills such as cognitive restructuring.
Behavioral activation helps us understand how
behaviors influence emotions, just like cognitive work
helps us understand the connection between thoughts
and emotions.
Here are some examples of how BA may be used:
Jim deals with depression and anxiety. He has a hard time figuring out why his
mood drastically dips and also finds it difficult to understand why he feels better
for short periods of time. While working with his schedule in therapy, he began
to discover specific mood triggers (how he spent his time or random events) that
he had never noticed before. He was able to become more aware of these
triggers and change his approach, ultimately allowing him to change his mood.
Debbie knew that her family history, stress with taking care of her special needs
son, and seasonal change contribute to her depression. Though she knows the
triggers, she struggles with managing her mood as she often does not feel like
doing activities that will help her depression. She often tells herself that she will
wait until it warms up outside to exercise and does not feel up to calling her
friends who usually cheer her up. With her therapist she began to find strategies
to help her motivation by practicing awareness of different avoidance patterns
and developing alternative, adaptive behaviors.
Will Behavioral Activation be helpful for me?
Behavioral activation is helpful for many people. If you answer “yes” to any of the following questions,
BA could be a good fit for you.
•Do I have a sense of what is triggering my mood or anxiety?
•Do I generally find myself doing very little, with little pleasure or meaning in my life?
•Are there times that I feel better or worse and I’m not sure why?
•Do I have a difficult time working with my negative thoughts, but seem to feel better when I can get
myself moving and doing something?
•Do I have a hard time even knowing what I enjoy or find meaning in?
5.2
Behavioral Activation is based on the well-researched understanding that
depression often keeps us from doing the things that bring enjoyment and
meaning to our lives. This “downward spiral” (explained in the first chapter of
this manual) causes us to feel even worse. In Behavioral Activation we work to
reverse this cycle using our actions and choices.
Behavioral Activation involves:
•
Understanding the “vicious cycles” of
depression
•
Monitoring our daily activities
•
Identification of goals and values
•
Building an upward spiral of motivation and
energy through pleasure and mastery
•
Activity Scheduling: purposefully scheduling
in enjoyable and meaningful activities
•
Problem solving around potential barriers to
activation
•
Reducing avoidance
•
Working as a team to make gradual,
systematic, sustained progress. Change
doesn’t happen over night!
•
Using between-session assignments. Practice
changes the brain, little by little!
“But my depression is ‘situational!’”
Yes, it is true that often depression is set in motion by difficult events that happen to us. If you are
dealing with a big loss, stressful situation, or change in your life, feelings of depression could be a
result. While it is important to address these external events and sometimes to talk about the past, it
is also important to find ways to address our current situation, find ways to fulfill on our future life
aims, and find time for enjoyment. Behavioral Activation can help with this part of treatment.
5.3
Action precedes emotion!?
We often wait to feel better or more motivated before
doing something.
Remember that anxiety and depression come from
parts of our brain that are really trying to protect us by
getting us to avoid or isolate. This means that as long
as we are following the lead of the anxiety and
depression, we will continue to feel less motivated and
want to avoid and isolate.
So why activate first? Firstly, activating changes our brain state and can make us
feel better, right away. For example, exercise can produce “good chemicals” in
the brain that lift mood while they are in the bloodstream. Secondly, the more
that we activate, the more situations we find ourselves in that can give us positive
experiences. The technical term for this is “reinforcing positive context
contingencies.” Technicalities aside, we need to “get out there” and give
ourselves the best chance of feeling better, even if we don’t feel like it at the
time.
So, when we are feeling anxious and depressed,
we cannot wait on the brain to give us the
motivation to get out there and do things.
Research has shown that our decision to activate (in
other words, to do the opposite of what the
depression wants us to do, and do something in
line with our values and goals) is necessary for
emotions to change.
Note: Behavioral Activation has
been shown in research studies to
be effective on its own for some
people to overcome depression.
However, it is often used alongside
other therapeutic skills, as it may
not address your specific situation
all by itself. Consider it just one of
many options in your effort to
manage depression.
On the next few pages we
illustrate the “vicious cycles” of
depression, according to the
research on depression and
Behavioral Activation.
5.4
Events often get
the depression
“ball rolling.”
This could be
something new
or a reminder
from a past
stressful event.
What happened
(stressful life events, triggers from past, etc.)
“I lost my job”
“We had our first child”
How you feel
(emotions)
Sad
Anxious
Stressed
Shut down
Embarrassed
The stress of
events leads to
negative
emotions that
are distressing
and make us
want to draw
back.
FIRST
VICIOUS
CYCLE
What you do
(or don’t do)
Emotions lead
to behaviors: we
avoid or isolate,
which makes us
feel worse.
Stay in bed
Don’t engage with family
Don’t return calls or texts
Avoid people
5.5
Avoidance,
isolation, and
other behaviors
cause further
negative events,
making us feel
even more
depressed.
What happened
(life events, triggers, etc.)
“I lost my job”
“We had our first child”
* Increased odds of more hardships and negative life events
My friends stop calling me because I never return calls or texts
SECOND
VICIOUS
CYCLE
How you feel
(emotions)
Sad
Anxious
Stressed
Shut down
Embarrassed
FIRST
VICIOUS
CYCLE
What you do
(or don’t do)
Stay in bed
Don’t engage with family
Don’t return calls or texts
Avoid people
5.6
Try to determine your own “vicious cycles,” identifying specific events, emotions, and responses.
What happened
(life events, triggers, etc.)
How you feel
(symptoms)
What you do
(or don’t do)
5.7
Being aware of our mood,
emotions, and behaviors is an
important part of CBT. In order to
know what to do to fix a problem,
we first need to understand what is
going on!
Activity Monitoring is the first step
of Behavioral Activation. It is
important to know exactly what we
are doing throughout the day, and
how this corresponds to our mood.
While we can’t fix the depression
just by noticing this, we can take a
step toward feeling better by
understanding which behaviors
help us feel better, which continue
to maintain the depression as it is,
and which make us feel worse.
Use the Activity Monitoring Chart
on the next page to start tracking
your activities and mood.
Get out that pen and paper!
Research shows that people who
write things down as part of CBT
practice do better than those that try
to do it all in their heads. While it
does involve more work (and may
seem like going back to school), we
hope you will give it a try at first, until
the skills become more natural.
5.8
With BA, we rate mood on a scale of 0-10, 10
being the best, 0 being the worst. We ask
people to rate mood in each hour to the best
of their ability in order to understand mood
changes.
For example:
Monday:!
8am: Woke up (5)!
9am: Went to go eat breakfast (6)!
10am: Got to work, talked to Bob (5)!
11am:Sitting at my desk reading e-mails (3)!
12pm:Eating lunch at my desk, worrying
about meeting (3)!
1pm:Meeting, thinking about issue with
reports that I missed, tired (3)!
2pm: Sitting at my desk working (4)!
3pm: Working (4)!
4pm: Working (4)!
5pm: Driving home (6)!
Instructions: Record your activity for each hour of the day (what you were doing, with whom,
where, etc.). Record a rating for your mood as you were doing each activity. Mood is rated
between 0-10, with “0” indicating “low mood” and “10” indicating “good mood.”
Sun
Mon
Tues
Wed
Thurs
Fr
Sat
5-7:00am
__________________________________________________________________________________________________________
7:00 am
__________________________________________________________________________________________________________
8:00 am
__________________________________________________________________________________________________________
9:00 am
__________________________________________________________________________________________________________
10:00 am
__________________________________________________________________________________________________________
11:00 am
__________________________________________________________________________________________________________
12:00 pm
__________________________________________________________________________________________________________
1:00 pm
__________________________________________________________________________________________________________
2:00 pm
__________________________________________________________________________________________________________
3:00 pm
__________________________________________________________________________________________________________
4:00 pm
__________________________________________________________________________________________________________
5:00 pm
__________________________________________________________________________________________________________
6:00 pm
__________________________________________________________________________________________________________
7:00 pm
__________________________________________________________________________________________________________
8:00 pm
__________________________________________________________________________________________________________
9:00 pm
__________________________________________________________________________________________________________
10:00 pm
__________________________________________________________________________________________________________
11:00 pm
__________________________________________________________________________________________________________
5.9
Based on the mood ratings you recorded on the Activity Monitoring Worksheet, determine which
activities helped you to feel more positive (“UP” activities) and which led to feeling down
(“DOWN” activities).
Antidepressant/UP Activities
Depressant/DOWN Activities
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
In Behavioral Activation, one of our aims is to increase “UP” activities and decrease “DOWN”
activities. Over the next section we will learn more about the types of activities that will lead to
better mood, to add to the list above. Over time, we can replace the “DOWN” activities with
more “UP” ones.
5.10
A Life Worth Living: Values, Pleasure, Mastery, and Goals
The next step in Behavioral Activation is determining the behaviors on which to
focus to improve our mood. While some behaviors, like exercise and meditation,
can be used right away to improve mood directly, many of the behaviors that are
likely to help us are those that align with the things that we enjoy or are
important to us.
An exploration of “values,” “pleasure,” and “mastery” describe much of the
“stuff” that makes life worth living. This process can help us come up with
tangible goals to move us toward the things that are most important to us.
“Values” are what we find meaningful in life. They
are the most important things to us. Everyone has
different values, and for each of us they can
change over time. They are like a compass,
pointing us in the direction we want to go.
“Pleasure” involves activities, or “play” that we enjoy for the sake
of the activity itself. Hobbies, games, spending time in nature, or
spending time with a good friend.
“Mastery” involves activities, such as work or sports, that
involve the development of skills; we are able to
accomplish things and feel a sense of mastery over our
environment. When enjoyed in moderation and
diversified well with other activities, they can increase
positive emotions and improve how we feel about
ourselves. Also, we may feel more creative as we learn to
master certain skills, adding to the possibilities of
enjoyment.
Goals and objectives outline the steps we take to experience our lives more
fully. They give us targets to help us experience more pleasure, mastery, and
value-driven behavior.
To feel more consistently engaged and happy in the world, it is usually best to
find a balance of goals centered on values, pleasure, and mastery. How that
balance looks for you will be unique. On the following pages, we will help you
understand how this balance might look for your own life.
5.11
As we mentioned earlier, “values” are what we find
meaningful and important. These can be different for
different people.
Values are important to explore, because much of our
goal-directed activity comes from a foundation of what
is valued. For example, one may value a healthy
lifestyle, and a related goal may be to exercise daily.
We may value family, and therefore choose to
schedule in time with them. Or if we don’t have a
family, our activities could lead to getting married and
starting one.
It is common to mistake certain wishes and feelings for
values. Values are not internal states, how people treat
us, or specific things to achieve.
On the next page is a list of values
that are related to the categories
below. Use them to start listing your
own values on the following page.
Below are some of the common areas of life that
people value and may lead to goal-directed activity.
Physical well-being
What kind of values do you
have regarding your physical
wellbeing? How do you want
to look at yourself?
Family relationships
What kind of relationships do you
want with your family? What kind of
mother/father/ brother/sister/uncle/
aunt do you want to be? What is
important to you about a good
family?
Intimate relationships
What kind of partner do you
want to be? What quality of
relationship do you want to be
part of? How do you want to
spend time together?
Citizenship/Community
Mental/Emotional Health
What kind of environment
do you want to be a part of?
How do you want to contribute to your community?
What helps you maintain
sound mental health? Why is
this important to you? What
issues would you like to
address?
Spirituality
Friendships/
social relations
What kind of relationship do
you want with God/nature/ the
Earth/mankind? What does
having a spiritual life mean to
you? How can you exercise this?
Hobbies/ Recreation
How would you like to enjoy
yourself? What relaxes you?
When are you most playful? Are
there any special interests you
would like to pursue?
What sort of friend do you want
to be? How would you like to
act towards your friends? How
can these relationships be
improved?
Education/training/
personal growth
How would you like to grow?
What kind of skills would you
like to develop? What would
you like to know more about?
Employment/career
What kind of work is valuable to
you? What qualities do you
want to bring as an employee?
What kind of work relationships
would you like to build?
5.12
Values, con.
Below is a list of general value categories, and some specific values that are common in each. See
if any of them fit you, and use this page to fill out the values rating sheet on the next page.
Family relations
•Work on current relationships
•Spend time with family
•Take an active role in raising my children
•Maintain consistent healthy
communication
Marriage/couples/intimate relationships
•Establish a sense of safety and trust
•Give and receive affection
•Spend quality time with my partner
•Show my partner how much I
appreciate them
Friendships/Social Relationships
•End destructive relationships
•Reach out for new relationships
•Feel a sense of belonging
•Have and keep close friends
•Spend time with friends
•Have people to do things with
Mental/Emotional health
•Seek fun and things that give me
pleasure
•Have free time
•Be independent and take care of myself
•Challenge my negative thinking
•Make my own decisions
•Engage in therapy
•Take my medications
•Stay active
Physical well-being
•Live in secure and safe surroundings
•Engage in regular exercise
•Have a steady income to meet physical
needs
•Eat foods that are nourishing to my
body
•Maintain a balance between rest and
activity
•Get enough sleep
5.13
Citizenship/Community
•Contribute to the larger community
•Help people in need
•Improve society
•Be committed to a cause or group that
has a larger purpose
•Make sacrifices for others
Spirituality
•Follow traditions and customs
•Live according to spiritual principles
•Practice my religion or faith
•Grow in understanding myself, my
personal calling, and life’s purpose
•Discern the will of God
•Find meaning in life
•Develop a personal philosophy of life
•Spend time in nature
•Focus on the greater good
Education/Training/Personal Growth
•Be involved in undertakings I believe
personally are significant
•Try new and different things in life
•Learn new things
•Be daring and seek adventure
•Have an exciting life
•Learn to do challenging things that help
me grow as a person
Employment
•Be powerful and able to influence
others, have authority
•Make important decisions that affect the
organization
•Be a leader
•Make a great deal of money
•Be respected by others
•Be seen by others as successful, be
ambitious
•Become well-known, obtain recognition
and status
•Be productive, work hard
•Achieve significant goals
•Enjoy the work I do
•Do what I’m told and follow the rules
Values, con.
Here are some other experiments to explore your own values:
1. Imagine that an important newscaster were doing a biographical story on your life.
Think about how you’d want them to describe you. How would they describe the way
you spent your time? How you related to others? What was most important to you?
What are your strengths as a person? Write down a narrative of what they would say.
2. Imagine you could read the mind of a person that’s important to you and with whom
you’ve had a good relationship. They are thinking all kinds of thoughts about your
qualities: what you stand for, what your strengths are, what you mean to him or her, and
the role you play in his or her life.
3. Think about your heroes. They can be people directly in your life, or other people that
you look up to, even fictional characters. What are their qualities? What do you admire
about them?
4. Imagine you are writing your own autobiography. Imagine how you would like to live
your life, barring all barriers, in the “best case scenario.” What are the things that are
most important to you in this scenario? What would you stand for? How would you
spend your time?
5. Imagine that someone is performing the eulogy at your funeral. Looking back on your
life, they would be commenting on your strengths, values, and achievements. How
would you want them to describe your life?
6. If you are struggling to find a valued direction, commit to experimenting with some of
the values on the previous pages for just one week. After choosing a value, plan to
notice your reactions to making the effort to hold to this value. Make a list of behaviors
that might fit with the value and choose one behavior to try. Notice your judgments
that come up about choosing this behavior. Then make a plan to fulfill on the valuedriven behavior. Just do the behavior without telling anyone about it and see what
happens. Commit to following through on this behavior once per day for one week.
Keep a diary of your reactions to behaving this way and others’ reactions to you. At the
end of the week, reflect on your experiment with someone else, like a therapist or
group leader.
5.14
Values Rating Sheet
Based on your exploration of the previous pages, write a summary of your values. For example,
“to live a healthy life and take care of my body” (physical well-being), or “to be a good friend
to people who need me, and to enjoy time with people I love”(friendships).
Rate each domain for how important it is to you from 0-10 (0 = not important, 10 = extremely
important).
Remember: values are not internal states, how people treat us, or specific things to achieve.
Physical well-being
Family relationships
Intimate Relationships
Mental/Emotional Health
Citizenship/Community
Spirituality
Other?
Hobbies/Recreation
Education/training/
personal growth
Friendships/social relations
Employment/career
5.15
The next step is to translate our values into activities that help us fulfill on those goals.
Take a moment to think about the values that you identified on the previous page. What are
some short term goals in each area? What are some long term goals? Use this page and the
next to start to brainstorm. Write down your results on the upcoming page: “Values, Pleasure,
and Mastery Master List.”
VALUE
ACTIVITIES
Parenting
Example:
I want to be involved in my
children’s interests and
learning. I’d like to build special
memories with my kids and
spend quality time with them.
I’m going to attend the
next PTO meeting and
maybe contact the
teacher to be a
classroom volunteer. I
can plan a small vacation
to take with the kids
next summer.
_________________
_________________
_________________
_________________
_________________
_________________
_________________
5.16
_________________
_________________
_________________
_________________
_________________
_________________
_________________
VALUE
ACTIVITIES
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
5.17
Pleasure
Pleasure involves activities that we enjoy for the sake of the activity itself. There are many different
kinds of pleasure. Those that are most sustainable involve “play” such as hobbies and other
recreational activities. Social activities can also involve pleasure. Other types of pleasure, such as
sensory experiences (food, drink, images, touch, etc.) can also be enjoyable if done in moderation.
Below are examples of enjoyable activities that are enjoyed by many. Circle the ones that apply to you,
and add others that aren’t included below.
Social activities
•
•
•
•
•
•
•
•
Hobbies, Interests, and other “play”
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Reading
TV, movies, plays
Dancing
Playing or listening to
music
Board games or cards
Arts and crafts, sewing, painting
Cooking
Walking, hiking, enjoying nature,
fishing
Sports (basketball, softball,
swimming, etc.) or going as a
spectator
Martial arts (karate, etc.)
Museums/zoos
Video games
Traveling, sightseeing, going
to the beach, sunbathing
Shopping
Gardening/decorating
Photography
Comedy: TV, recordings, live
Religion or spirituality
•
Spending time with family
Enjoying own children and/or young
relatives
Enjoying close friends
Hanging out with large
groups of friends/acquaintances
Parties, meeting new people
Romance
Pets
Clubs: meeting people with similar
interests
Enjoying food and drink with others
Sensory experiences
•
•
•
•
Pleasant smells, images, sounds,
physical touch, tastes
Taking a bath
Listening to soothing music
Mindful tasting
Other?
____________________________________________
_____________________________________________
_____________________________________________
5.18
Mastery
Mastery involves activities, such as work or sports, that involve the development of
skills; we are able to accomplish things and feel a sense of mastery over our
environment. When enjoyed in moderation and diversified well with other activities,
they can increase positive emotions and improve how we feel about ourselves.
Here are some examples of how people experience mastery to experience fulfillment
in their lives. Circle the ones that apply to you, and add others that aren’t included
below.
Job or Meaningful Daytime Activity
Look for or attempt to develop some of these
qualities in your occupation volunteer work, or
other meaningful daytime activity:
•
•
•
•
•
•
Enjoyment
Creativity
Feelings of competence (able to
accomplish tasks satisfactorily)
Potential for development of skills
Ability to “move up” in the organization or
take on more responsibility, if this is
desired
Social contact with coworkers, colleagues,
others in the field
Other skill-based activities
•
•
•
•
•
Sports
Music practice and performance
Home improvement/building
Woodworking
Visual art (painting, drawing,
pottery, sewing, knitting
• Learning about interests
(history, politics, food,
language, culture, etc.)
• Crafting, pottery, and other
creative skills
Other?
____________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
5.19
Here are some examples of activities that tend to increase pleasure and mastery. You might think of more
that are not listed. Circle the ones that you think could lead to enjoyment or mastery for yourself.
1. Soaking in the bathtub
2. Planning my career
3. Collecting things (coins, shells, etc.)
4. Going for a vacation
5. Recycling old items
6. Relaxing
7. Going on a date
8. Going to a movie
9. Jogging, walking
10. Listening to music
11. Thinking I have done a full day’s work
12. Recalling past parties
13. Buying household gadgets
14. Lying in the sun
15. Planning a career change
16. Laughing
17. Thinking about my past trips
18. Listening to others
19. Reading magazines or newspapers
20. Hobbies (stamp collecting, model building,
etc.)
21. Spending an evening with good friends
22. Planning a day’s activities
23. Meeting new people
24. Remembering beautiful scenery
25. Saving money
26. Gambling
27. Going to the gym, doing aerobics
28. Eating
29. Thinking how it will be when I finish school
30. Getting out of debt/paying debts
31. Practicing karate, judo, yoga
32. Thinking about retirement
33. Repairing things around the house
34. Working on my car (bicycle)
35. Remembering the words and deeds of
loving people
36. Wearing sexy clothes
37. Having quiet evenings
38. Taking care of my plants
39. Buying, selling stocks and shares
40. Going swimming
41. Doodling
42. Exercising
43. Collecting old things
44. Going to a party
45. Thinking about buying things
46. Playing golf
47. Playing soccer
48. Flying kites
49. Having discussions with friends
50. Having family get-togethers
51. Riding a motorbike
52. Sex
53. Playing squash
54. Going camping
55. Singing around the house
56. Arranging flowers
57. Going to church, praying (practicing
religion)
58. Losing weight
59. Going to the beach
60. Thinking I’m an OK person
61. A day with nothing to do
62. Having class reunions
63. Going ice skating, roller skating/blading
64. Going sailing
65.Travelling abroad, interstate or within the
state
66. Sketching, painting
67. Blowing bubbles
68. Doing embroidery, cross stitching
69. Sleeping
70.Driving
71.Entertaining
72. Going to clubs (garden, sewing, etc.)
73. Thinking about getting married
74. Going bird watching
75. Singing with groups
76. Flirting
77. Playing musical instruments
78. Doing arts and crafts
79. Making a gift for someone
80. Buying CDs, tapes, records
81. Watching boxing, wrestling
82. Planning parties
83. Cooking, baking
84. Going hiking, bush walking
85. Writing books (poems, articles)
86. Sewing
87. Buying clothes
88. Working
89. Going out to dinner
90. Discussing books
91. Sightseeing
92. Gardening
93. Going to the beauty salon
94. Early morning coffee and newspaper
95. Playing tennis
96. Kissing
97. Watching my children (play)
98. Thinking I have a lot going for me
99. Going to plays and concerts
100. Daydreaming
101. Planning to go to college or university
5.20
102. Going for a drive
103. Listening to a stereo
104. Refinishing furniture
105. Watching videos or DVDs
106. Making lists of tasks
107. Going bike riding
108. Walks on the riverfront/shoreline
109. Buying gifts
110. Travelling to national parks
111. Completing a task
112. Thinking about my achievements
113. Going to a sporting event
114. Eating gooey, fattening foods
115. Exchanging emails, chatting on the
internet
116. Photography
117. Going fishing
118. Thinking about pleasant events
119. Staying on a diet
120. Star gazing
121. Flying a plane
122. Reading fiction
123. Acting
124. Being alone
125. Writing diary/journal entries or letters
126. Cleaning
127. Reading non-fiction
128. Taking children places
129. Dancing
130. Going on a picnic
131. Thinking “I did that pretty well” after
doing something
132. Meditating/ Mindfulness exercises
133. Playing volleyball
134. Having lunch with a friend
135. Making a gratitude list
136. Thinking about having a family
137. Thoughts about happy moments in my
childhood
138. Splurging
139. Playing cards
140. Having a political discussion
141. Solving riddles mentally
142. Playing tennis
143. Seeing and/or showing photos or slides
144. Knitting/crocheting/quilting
145. Doing crossword puzzles
146. Shooting pool/Playing billiards
147. Dressing up and looking nice
148. Reflecting on how I’ve improved
149. Buying things for myself
150. Talking on the phone
151. Going to museums, art galleries
152. Thinking religious thoughts
153. Surfing the internet
154. Lighting candles
155. Listening to the radio
156. Spending time in nature
157. Having coffee at a cafe
158. Getting/giving a massage
159. Saying “I love you”
160. Thinking about my good qualities
161. Buying books
162. Having a spa, or sauna
163. Going skiing
164. Going canoeing or white-water rafting
165. Going bowling
166. Doing woodworking
167. Fantasizing about the future
168. Doing ballet, jazz/tap dancing
169. Debating
170. Playing computer games
171. Having an aquarium
172. Erotica (sex books, movies)
173. Going horseback riding
174. Going rock climbing
175. Thinking about becoming active in the
community
176. Doing something new
177. Making jigsaw puzzles
178. Thinking I’m a person who can cope
179. Playing with my pets
180. Having a barbecue
181. Rearranging the furniture in my house
182. Buying new furniture
183. Going window shopping
184. Saying yes to an opportunity
5.21
Values, Pleasure, and Mastery Activities List
Look back at the last 6 pages and write down the activities you came up with to form a
master list of possible activities that fit with your life aims. We’ll use these to start to
get more active with Behavioral Activation.
Pleasure
Mastery
1. _____________________________________
1. _____________________________________
2. ______________________________________
2. ______________________________________
3. ______________________________________
3. ______________________________________
4. ______________________________________
4. ______________________________________
5. ______________________________________
5. ______________________________________
6. ______________________________________
6. ______________________________________
7. ______________________________________
7. ______________________________________
8. ______________________________________
8. ______________________________________
9. ______________________________________
9. ______________________________________
10. ____________________________________
10. ____________________________________
Valued Activities
1. __________________________________________________________________________
2. __________________________________________________________________________
3. __________________________________________________________________________
4. __________________________________________________________________________
5. __________________________________________________________________________
6. __________________________________________________________________________
7. __________________________________________________________________________
8. __________________________________________________________________________
5.22
Goal Setting
Goals are how we make our values, pleasure, and mastery
activities real and practical. On the next few pages we will
start to schedule the activities that we recorded on the
Values, Pleasure, and Mastery Activities List. Before we do,
it is important to be sure we are being “SMART” about
setting these goals. Use the following tips to increase the
chances of reaching your goals.
In order for goals to be achieved, they must be “SMART:”
Specific: when creating a goal, state exactly what you want to achieve.
Think about how and when you are going to achieve your goal. For
example, “I want to lose ten pounds in two months by counting calories.”
Measurable: in order to say you met a goal, one must be able to
measure it. Stating that “I want to eat more fruits and vegetables” is not
as measurable as stating “I want to eat a combination of 5 fruits and
vegetables a day.”
Attainable: Is the goal possible? If the goal is to get into shape by
swimming 30 laps a day and you have never swum for exercise, you will
be setting yourself up for avoidance and discouragement. Choose a
smaller goal, like taking a few swimming lessons or just swimming a few
laps to start.
Realistic: is the goal realistic? If you have had a knee injury or chronic
pain, it is probably not realistic to set a goal for yourself of joining a
kickboxing class. Perhaps joining a walking program would be more
realistic.
Trackable: tracking your progress helps us notice improvement. When
we recognize our improvement, it motivates us to continue our good
work. It can also help in creating future goals.
5.23
So far, we have…
•
…determined how you spend your
time and how your current activities are
associated with your mood.
•
…started to understand your values,
enjoyable activities, and activities that
make you feel a sense of mastery and
accomplishment. We’ve connected
these with specific activities that you
wrote on the Values, Pleasure, and
Mastery Activities List.
•
…learned how to be smart about
setting goals.
Now it’s time to start activating! One way to make Behavioral Activation work is
to simply start to schedule activities and then rate how our mood corresponds
to each activity. Use the chart on the following page to choose some activities
with which to start. You’ll check the ones you complete and then rate your
mood during the activity.
Activity Planning Tips:
•Start with 2-3 of the easiest activities.
•Schedule activities on the day and time you think you could reasonably complete them. For
example, if my activity is “play with my daughter” I might enter that activity at 11 am on
Monday, 10 am on Wednesday, and 9 am on Thursday.
•Consider whether you are ready for a particular activity and consider any barriers. For
example, if my activity is “exercise,” one barrier might be that I don’t have any gym clothes.
Perhaps I need to first complete the activity “purchase gym clothes” before I’ll be ready to hit
the gym.
•If you are unable to do an activity on the day or time that you first planned, just cross it out,
write the activity that you did that that time, and try to reschedule your planned activity.
•Remember not to get discouraged if you aren’t able to complete all of the activities. Try to
continue to move forward with the activity anyway, even if it isn’t going as you hoped.
5.24
5.25
Instructions: Write some specific activities that you recorded on the “Values, Pleasure, and Mastery Activities List” in
the “activity” column. Place a check in the “completed” column to indicate if you completed the scheduled activity.
Record a mood rating in the last row; mood is rated between 0-10 (“0” indicating “most negative” and “10”
indicating “most positive.”
Activity
Completed
Mood rating
5-7:00 am
__________________________________________________________________________________________________________
7:00 am
__________________________________________________________________________________________________________
8:00 am
__________________________________________________________________________________________________________
9:00 am
__________________________________________________________________________________________________________
10:00 am
__________________________________________________________________________________________________________
11:00 am
__________________________________________________________________________________________________________
12:00 pm
__________________________________________________________________________________________________________
1:00 pm
__________________________________________________________________________________________________________
2:00 pm
__________________________________________________________________________________________________________
3:00 pm
__________________________________________________________________________________________________________
4:00 pm
__________________________________________________________________________________________________________
5:00 pm
__________________________________________________________________________________________________________
6:00 pm
__________________________________________________________________________________________________________
7:00 pm
__________________________________________________________________________________________________________
8:00 pm
__________________________________________________________________________________________________________
9:00 pm
__________________________________________________________________________________________________________
10:00 pm
__________________________________________________________________________________________________________
11:00 pm
__________________________________________________________________________________________________________
Scheduled Activities for (name):
___
Day of week/date _______
Pleasure Predicting
We are depressed we often anticipate getting little to no pleasure or
mastery out of an activity. Depression clouds our judgment and colors
our predictions about the future.
As an experiment, we can “pleasure predict” how much pleasure or
mastery we feel after a given activity. This is one way that we can mix
Behavioral Activation with the Cognitive Skills we learned in Chapter 4.
We perform a “behavioral experiment,” which means that we see what
happens when we plan an activity, recording the “data,” to see what we
learn. People tend to learn that activities are more enjoyable than they
had predicted. See what happens for you!
Use the sheet on the following page
to “pleasure predict” some activities
this week.
First, pick an achievable activity,
especially one that you predict may
not be enjoyable. Schedule the
activity using the Activity Planning
Worksheet on the previous page.
Fill in the form on the next page,
recording your “prediction” before
you start the activity on a scale of
0-10. Right after the activity is
finished, record how much you
actually enjoyed it.
5.26
Activity
Activity
Activity
(Schedule activities with a
potential for pleasure or
personal growth)
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
Companion(s)
(If alone, specify “self”– do
not put the word “alone” in
this column)
Companion(s)
Companion(s)
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
Satisfaction
(rate on scale of 0-10)
Satisfaction
(rate on scale of 0-10)
Satisfaction
(rate on scale of 0-10)
Predicted Actual___
Predicted Actual___
Predicted Actual___
___________________
___________________
___________________
5.27
When a problem arises, there many possible responses. As we have discussed throughout this manual,
some responses to depression and problems can help to solve these problems; others can serve to
make things worse. Below we describe three ways of addressing a problem. One approach may work
best, or all three may apply. The “take home point” here is that all situations are different, and require
different types of approaches to help you meet your life aims.
Adaptive Response #1: Get the facts (thinking)
Use cognitive skills to better understand the “facts” of a situation. Perhaps there
is a problem, and perhaps there is not. Sometimes the first step is to understand
the facts of a situation, and then decide whether or not to use problem solving
skills (below) or accept things that are outside of our control. Also see the earlier
section on “Cognitive Therapy Skills.”
Adaptive Response #2: Problem solving (actions/behaviors)
Sometimes the best answer to a problem is working to “solve” the problem
somehow—it is not a problem with our thinking or behavior, it is a problem with
the external circumstances. For example, if someone is consistently aggressive
or abusive of us, we may want to find a way to set firm limits with that person or
leave the relationship altogether. There are many problem solving skills, some of
which are outlined below:
-Behavioral Activation skills to address avoidance
-Assertively address interpersonal conflicts
-Take small steps to make progress on long-term projects
-Plan for the future
-Manage your time effectively
-many others…
Talk to your therapist or group leader about other behavioral skills to directly
address problems that arise.
Adaptive Response #3: Accept what cannot be controlled (letting go)
There are times that we believe we should be able to control something,
yet our consistent attempts to do so are met with failure. This “beating a
dead horse” makes us more and more frustrated, angry, anxious, and
depressed. Sometimes letting go of things we cannot control is
necessary to prevent problems from getting even worse; we also lift
some of the burden of failing over and over.
How to take action
to solve a problem
1. Write down clearly what
the problem is.
2. Brainstorm about ways
to solve the problem, even
“ridiculous” ways, writing
down all possibilities.
3. Rank the possible
solutions in order, from
best to worst. Think “how
likely is it for this approach
to work?”
4. Decide on a plan of
action for each reasonable
solution. Rate how
probable it would be each
each plan to work.
5. Pick the most reasonable
plan and put the plan into
action. If it doesn’t work,
go to the next best
solution and try that one.
Continue to try until you
solve the problem.
How do I know what to do to make it better?
Sometimes it is difficult to know which approach to take to make a situation better. While it is
ultimately an individual decision, one that may take trial and error, therapy is a place to work out
some of these difficult choices. The various skills in CBT are meant to help us get some clarity
around some of these decisions. While we don’t have room in this manual to discuss in detail how to
make these decisions, this is something to discuss with your group or individual therapist as you
move through treatment.
5.28
If you are experiencing depression, chances are you’re
dealing with motivational difficulties. Frequently we hear
people (depressed or not) talk about waiting to make
changes when they are “ready” as if there is a particular
day that they will wake up and suddenly feel different
and able to face whatever it is they are avoiding. We put
off exercise routines, diets, getting homework done,
calling back important people, etc., because we feel
unmotivated.
From the outside-in…
As we discussed in the “Action Precedes Emotion?” section earlier, one reason we
struggle with motivation is that we are looking to our internal emotional state
(happy, energized, excited) to cue us to start a task. This is an “inside-out” way of
thinking which is problematic with depression, because for most people, low
motivation/energy is a pervasive symptom that typically takes some time to resolve.
In Behavioral Activation we ask people to work from the outside-in, acting
according to a plan rather than waiting to feel ready. We can jump-start our mood
by starting with an action and letting our mood follow. This is hard at first, but over
time, most people recognize that their actions can actually have an impact on their
mood, so they feel less at the mercy of their depression.
Little by little…
Working on doing things that you have been avoiding can sometimes feel
painful or even cause some anxiety. While plunging into these behaviors
might seem ideal, you will likely have more success if you commit to taking
small steps.
For example, if you and your therapist identify exercise as a goal, you might break this down into
steps.
If you’d like to run, but you’ve been inactive for months, chances are you’re not going to just start
running. By breaking this down into smaller goals you will likely have more success. Let’s say you
set a goal to put on your shoes and walk for 10 minutes, then 20, then 30, etc. Once you’ve built
some momentum, you then might begin to run.
Use the “Motivation Tips” on the following page to help you get unstuck when low motivation
strikes.
5.29
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Keep it simple
Break it into smaller pieces
Do one thing at a time
Set realistic goals
Schedule activities at times when you are most
likely to succeed
Use self-compassion
Anticipate setbacks
Reinforce and reward healthy behavior choices
Reflect on what works and what doesn’t work
Change your environment
Minimize distractions
Use visual reminders
Talk yourself into it—challenge negative
thinking!
Use a timer—start with just five minutes
Use reminders/alarms
Have an accountability partner
Focus on long-term benefits
Commit to making decisions based on what we
know, not on what we feel
5.30
Behavioral Activation Tips
Behavioral Activation can be challenging! It
is common to run into roadblocks during this
process and have moments in which we
want to give up. We can honestly say that
the only barrier to improvement is giving up
completely; if you continue to learn about
your valued life course and stay “out there,”
chances are that things will improve.
Use the tips below to help navigate barriers that come up during the course of
Behavioral Activation treatment.
1. Be prepared for a challenge: because we are working against our brain’s
attempts to protect us, it takes effort and some discomfort to get results
from Behavioral Activation in the long run.
2. Get “back on the horse:” when failures inevitably happen, be prepared to
respond actively. Depression will tell us to give up when things don’t go
well… and try to convince us that all of those negative thoughts are the
truth. Prove the depression wrong by getting back out there and moving
toward what you really value.
3.
Move one step at a time: retraining the brain takes time, one small step at
a time. Trying to move too quickly is a recipe for failure and
disappointment, and overwhelms us so that we want to give up.
4. Address negative thinking: go back and review the Cognitive Therapy
Skills chapter and continue to address the thinking that tries to keep us
isolated. Especially address self-critical thoughts and develop selfcompassion.
5. Focus on valued action, not just on “symptom reduction.” Gauge success
according to the extent that you are living a valued life, not whether or
not you have emotions. While one aim of CBT is to improve mood and
have fewer negative emotions in the long run, in the short run we must
remember that emotions are a part of life and we cannot get rid of them
completely. But… we can improve life and how we feel by moving toward
valued actions.
5.31
Continued on the next page…
Behavioral Activation Tips, con.
6. Monitor your activities and mood as specifically as you can. We often
miss important clues to treating depression when we don’t pay enough
attention to the details of our activity.
7. Solve problems that could be leading to further depressive symptoms,
and work to accept those things that cannot be solved, while continuing
to move toward life aims to the best of your ability.
8. Be sure your activities line up with your true values. Sometimes we think
we are living a valued life and we are not; this leads to continual
disappointments. Continue to explore your values. Remember that
values are not internal states, how people treat us, or specific things to
achieve.
9.
Be sure you have the skills you need to be successful. Trying to do
something in which we don’t have the necessary skills sets us up for
failure. Some people learn that they are “incompetent,” only because
they continue to try to do things for which they are not ready. Find out
what skills are necessary to be successful at a given task, and then, given
the amount of work it would take to learn the necessary skills, decide if it
makes sense to continue to pursue that activity.
10. Understand the principles of Behavioral Activation and why each part of
it is necessary. Sometimes we are confused about why we are doing
something; this potentially leads to resistance to trying new things, and
we miss out on the possible benefits.
11. Practice mindfulness: review Chapter 3 and practice mindfulness.
Research shows that enjoyment is much more likely when we are present
and mindful. Use Behavioral Activation as an opportunity to practice
being mindful of potentially pleasurable experiences as they occur.
12. Reward yourself for your achievements. Depression and self-criticism try
to take away the “kudos” we deserve when we achieve something. Make
an explicit effort to reward yourself instead.
5.32
Barriers and Resources Worksheet
Use the following worksheet to determine the specifics of some of your
goals. Think about possible barriers and resources you might have to
hurdle them.
Goal: _____________________________________________________________
When I want to achieve it:___________________________________________
__________________________________________________________________
How I am going to do it:_____________________________________________
__________________________________________________________________
How I am going to measure it:_______________________________________
__________________________________________________________________
What are possible barriers?__________________________________________
__________________________________________________________________
What are the possible resources?_____________________________________
__________________________________________________________________
5.33